Provider Demographics
NPI:1225570732
Name:OMNI DERMATOLOGY ESTRELLA LLC
Entity type:Organization
Organization Name:OMNI DERMATOLOGY ESTRELLA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:RACETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-954-3919
Mailing Address - Street 1:4840 E INDIAN SCHOOL RD
Mailing Address - Street 2:STE 102
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-5500
Mailing Address - Country:US
Mailing Address - Phone:602-954-3919
Mailing Address - Fax:602-954-3670
Practice Address - Street 1:9305 W THOMAS RD
Practice Address - Street 2:STE 350
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3328
Practice Address - Country:US
Practice Address - Phone:623-478-8000
Practice Address - Fax:623-478-8003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty